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Crystal Nguyen, with her 6-year-old son, Neiko, in Pittsburg, Calif., is a former Valley State Prison for Women inmate. She worked in the prison's infirmary in 2007 and says she often overheard medical staff asking inmates who had served multiple prison terms to agree to be sterilized. Now, California state auditors say they have found 39 cases where female state prison inmates may not have understood they were submitting to medical procedures that would leave them sterile.

California state auditors found 39 cases where female state prison inmates may not have understood they were submitting to medical procedures that would leave them sterile, according to a report released Thursday that recommended authorities investigate the doctors and hospitals involved.

State law prohibits inmates from elective sterilizations as methods of birth control. However, prison officials allow sterilizations in cases deemed medically necessary.

The audit was prompted by the Center for Investigative Reporting, which last year found that doctors sterilized nearly 150 female prisoners without obtaining proper consent. Auditors confirmed 144 cases between 2006 and 2013 in which inmates had their fallopian tubes tied or cut for the sole purpose of birth control.

The report identified 39 "unlawful" cases with apparent violations of state rules requiring inmates understand the nature and permanence of the procedures.

Margarita Fernandez, a spokeswoman for the California State Auditor, said those "tubal ligation" sterilizations involved 17 doctors and eight hospitals. The sterilizations were performed by private doctors at facilities outside the prisons, which is typical, she said. No names were released.

The cases will be referred to California's medical board and the Department of Public Health, said Liz Gransee, a spokeswoman for the federal court-appointed official who controls prison medical care.
State Sen. Hannah-Beth Jackson called the findings shocking. She said she fears that inmates may feel pressure to undergo sterilization.

"The experience in and of itself is extraordinarily coercive," Jackson said of obtaining health care behind bars. "It's very difficult for a woman to exercise her free will under those circumstances."

Jackson, D-Santa Barbara, is the author of a bill that would make it clear that the state's prisons and jails are prohibited from sterilizing inmates for the purpose of birth control. The measure passed the Senate 36-0 last month and is before the Assembly. Auditors said there was confusion over the prison policy.

The federal receiver's office took control of prison medical care in 2006, but said it didn't learn about the sterilization procedures until the legal advocacy group Justice Now raised the issue in January 2010. The receiver's office previously said it immediately took steps to stop the practice.

The report found one sterilization since then, in 2011, but said the tubal ligation was medically necessary. But in 27 cases auditors found the inmate's doctor did not sign a required consent form saying the patient appeared mentally competent, understood the permanent effect and had waited at least 30 days and no more than 180 days to reconsider.

Auditors were critical of the receiver's office, saying it failed to make sure its staff obtained necessary approvals from inmates and from two medical procedure review committees before inmates were sterilized. They recommended that the federal receiver adopt better procedures to monitor its medical staff and the medical providers who work under contract with the state. That includes improving medical record-keeping and making sure inmates give their informed consent to medical procedures.
Gransee put a positive spin on the findings.

"We are glad to see that our efforts to stop the practice have been successful," she said, adding the receiver's office will work with auditors "to improve our process further.”